Glass

Diagnosis: Non-ST-elevation myocardial infarction (NSTEMI). The patient presented with acute-onset chest pain and diaphoresis, which could be consistent with a non-ST-elevation myocardial infarction. The presence of elevated cardiac biomarkers such as troponin could further suggest this diagnosis.

Diagnosis: Unstable angina. The patient presented with acute-onset chest pain and diaphoresis, which could be consistent with unstable angina. The absence of elevated cardiac biomarkers could further suggest this diagnosis.

Diagnosis: Acute coronary syndrome due to coronary artery vasospasm. The patient presented with acute-onset chest pain and hyperacute T-waves without ST elevation, which could be consistent with coronary artery vasospasm causing acute coronary syndrome. The presence of a history of smoking or stimulant drug use could further suggest this diagnosis.

Diagnosis: Spontaneous coronary artery dissection (SCAD). The patient presented with acute-onset chest pain and hyperacute T-waves without ST elevation, which could be consistent with spontaneous coronary artery dissection. The presence of younger age, female gender, lack of cardiovascular risk factors other than diabetes and hyperlipidemia, and sudden onset of symptoms could further suggest this diagnosis.

Diagnosis: Gastroesophageal reflux disease (GERD). The patient presented with acute-onset chest pain, which could be consistent with gastroesophageal reflux disease. The presence of burning substernal epigastric pain aggravated by a large meal or recumbency and improved by antacids could further suggest this diagnosis. However, it is important to note that a history of GERD does not exclude the possibility of an acute coronary syndrome.

Diagnosis: Ischemic Stroke.

The patient presented with confusion and disorientation, which could be consistent with an ischemic stroke. The presence of a history of hypertension, diabetes, and previous strokes could further suggest this diagnosis. Additional information such as focal neurological deficits or acute onset of symptoms would strengthen the likelihood of an ischemic stroke.

Diagnosis: Subdural Hematoma.

The patient presented with confusion and disorientation after a fall, which could be consistent with a subdural hematoma. The presence of progressively worsening focal neurological findings on exam could further suggest this diagnosis. A brain CT scan showing a crescent-shaped collection of blood would confirm the diagnosis.

Diagnosis: Traumatic Brain Injury.

The patient presented with confusion and disorientation following a fall, which could be consistent with a traumatic brain injury. The presence of loss of consciousness and/or post-traumatic amnesia could further suggest this diagnosis. Confirmation would require imaging studies such as a brain CT scan demonstrating edema and skull fracture or diffusion tensor imaging or FLAIR abnormalities on MRI for milder injuries.

Diagnosis: Hypoglycemia.

The patient presented with confusion and disorientation, which could be consistent with hypoglycemia given their history of diabetes. The presence of additional symptoms such as sweating, shakiness, and decreased consciousness could further suggest this diagnosis. Measurement of the patient's blood glucose levels below 70 mg/dL would confirm hypoglycemia.

Diagnosis: Delirium.

The patient presented with confusion and disorientation, which could be consistent with delirium. The presence of changes in perception such as hallucinations, delusions, or illusions, and sleep-wake cycle disturbance such as insomnia or excessive drowsiness could further suggest this diagnosis. Identifying potential precipitating factors, such as medications, infections, or metabolic disturbances, would aid in determining the underlying cause of delirium.

A 71-year-old male with a history of myocardial infarction presents with subacute progressive dyspnea on exertion. Physical examination reveals bilateral lower extremity edema, an S3 heart sound, and jugular venous distension (JVD). The patient's ejection fraction (EF) is newly found to be 30%, indicating heart failure with reduced ejection fraction (HFrEF). The differential diagnosis includes acute decompensated heart failure (ADHF), ischemic cardiomyopathy, valvular heart disease, and pulmonary hypertension.

Dx:

• Strict I/Os, QD standing weights
• Tele
• ECG
• BNP or NT-proBNP, +/- troponin
• BID BMP + Mg, goal K>4.0, Mg>2.0
• TTE
• Lipid panel, HbA1c
• Iron, TIBC, Ferritin
• ANA, RF, HIV, SPEP/UPEP, serum FLCs, TSH w/ free T4 for new Dx of HF
• Consider ischemic evaluation for new Dx of HF (CT coronary, Coronary Angiogram, Stress test)

Tx:

Preload

• IV diuresis at 2.5x home diuretic dose (known CHF) OR IV furosemide 0.5-1 mg/kg
• Consider increasing IV diuretic dose up to 300 mg daily furosemide equivalents for goal daily net I/O neg 1.5-2L.
• Consider augmenting diuresis w/ metolazone 2.5-5.0 mg PO or chlorothiazide 500mg IV to reach diuresis goal
• If overload is resistant to scheduled diuretics, consider IV furosemide gtt (furosemide 0-20 mg/h)
• If significant K requirement, consider K-sparing diuretic
• Consider augmenting diuresis with acetazolamide, amiloride, or aldosterone antagonist to reach the diuresis goal
• HOLD beta-blockade (metoprolol succinate, bisoprolol, carvedilol) iso significant decompensation/inotrope requirement
• 2g NA, 2L Fluid restriction

Afterload

• Consider initiation of ACEi, ARB, or ARNI for afterload reduction
• Consider Isordil or hydralazine if additional afterload reduction is needed

Device

• Monitor diuresis and consider whether a device is warranted

Iron Repletion

• Replete iron with IV iron for ferritin >100 or transferrin saturation <20% based on initial labs (FAIR-HF, AFFIRM-AHF)

Guideline Directed Medical Therapy (GDMT)

• For HFrEF (EF ≤40%), consider BB (metorpolol, carvedilol, or bisoprolol), ACEi/ARB/ARNI, MRA, SGLT2i, statin, cardiac resynchronization therapy, and ICD.{"completion_uuid": "9ccb7b81-1b98-4480-8d4a-3efe8db03add", "references_text": "Felker, G. M., Ellison, D. H., Mullens, W., Cox, Z. L., & Testani, J. M. (2020). Diuretic Therapy for Patients\u00a0With\u00a0Heart\u00a0Failure. Journal of the American College of Cardiology, 75(10), 1178\u20131195. <part>https://doi.org/10.1016/j.jacc.2019.12.059<ref>Felker, G. M., Lee, K. L., Bull, D. A., Redfield, M. M., Stevenson, L. W., Goldsmith, S. R., . . . O\u2019Connor, C. M. (2011). Diuretic Strategies in Patients with Acute Decompensated Heart Failure. New England Journal of Medicine, 364(9), 797\u2013805. <part>https://doi.org/10.1056/nejmoa1005419<ref>Fonarow, G. C., Abraham, W. T., Albert, N. M., Gattis, W. A., . . . Young, J. (2004). Organized program to initiate lifesaving treatment in hospitalized patients with heart failure (OPTIMIZE-HF): rationale and design. American Heart Journal, 148(1), 43\u201351. <part>https://doi.org/10.1016/j.ahj.2004.03.004<ref>Maw, A. M., Hassanin, A., Ho, P. M., . . . Daugherty, S. L. (2019). Diagnostic Accuracy of Point-of-Care Lung Ultrasonography and Chest Radiography in Adults With Symptoms Suggestive of Acute Decompensated Heart Failure. JAMA Network Open, 2(3), e190703. <part>https://doi.org/10.1001/jamanetworkopen.2019.0703<ref>Nohria, A., Tsang, S. W., Fang, J. C., . . . Stevenson, L. W. (2003). Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. Journal of the American College of Cardiology, 41(10), 1797\u20131804. <part>https://doi.org/10.1016/s0735-1097(03)00309-7<ref>Sharma, A., Verma, S., Bhatt, D. L., Connelly, K. A., Swiggum, E., Vaduganathan, M., Zieroth, S., & Butler, J. (2022). Optimizing Foundational Therapies in Patients With HFrEF. JACC: Basic to Translational Science, 7(5), 504\u2013517.<part>https://doi.org/10.1016/j.jacbts.2021.10.018<ref>Wang, C. S. (2005). Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? JAMA, 294(15), 1944. <part>https://doi.org/10.1001/jama.294.15.1944"}